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November 2014



Volume 11, Issue 9


The Lame Duck Congress and Health Care Spending
Preserve Funding for Nursing Programs in FY 2015


NLN Government Affairs Action Center
NLN Public Policy


As expected, Republicans won enough seats in the 2014 midterms to take control of the Senate. The outcome of the recent elections will have profound implications for health care policy. Most significantly, the fight for control of the Senate will shape the tenor and content of the health care debate in Washington for at least the next two years.

The Republicans' congressional victories position them to take aim at significant provisions of the Patient Protection and Affordable Care Act (ACA) that could endanger its long-term viability. Targets are expected to include provisions of the law such as the employer and individual insurance mandates and excise taxes on medical devices and health plans. Another likely target is the 30-hour-per-week definition of full-time work. The budget reconciliation process could be crucial to these efforts because it allows for passage in the Senate with only 51 votes instead of the 60 votes needed to break filibusters.

However, many of these changes will cost money. For example, according to the Congressional Budget Office (CBO), raising the bar for full-time work to 40 hours would cost $83 billion over a decade. Eliminating the 2.3 percent tax on medical devices would cost $29 billion over a decade, according to the Joint Committee on Taxation. Delaying the individual mandate would save roughly $170 billion in subsidy payments over a decade, but it would also mean 13 million fewer Americans with insurance by 2018, according to CBO. Republicans will need to find ways to pay for such changes, a task that is not going to be easy to achieve.

At the state level, the re-election of Republican governors in closely contested races in Florida, Georgia, Wisconsin, Maine, and Kansas dims the chances of Medicaid expansion in those states. "No one would say it was a good night for the prospects of Medicaid expansion," said Joan Alker, executive director of the Center for Children and Families at Georgetown University. However, Alker also said the playing field for Medicaid expansion didn't shift dramatically. "The debate continues to be within the Republican Party - with more pragmatic Republicans saying yes and ideologues driving the opposition. So what happens next is a good test case to see how Republicans will resolve these internal tensions."

Since the Supreme Court made Medicaid expansion an optional part of the ACA, 27 states and Washington, DC have extended the program to individuals with incomes under $16,100. While most of those states expanded eligibility at the beginning of 2014, Michigan and New Hampshire came on later this year and Pennsylvania's expansion will start in January. Nationally, Medicaid enrollment has increased by more than eight million people since last October and has been seen as the biggest factor in reducing the number of uninsured Americans by about 25 percent this year.

The Lame Duck Congress and Health Care Spending

For the remainder of 2014, the major emphasis during the lame duck session will be on legislation and what gets taken up in earnest. Some pundits say that repeal of a medical device tax that could win bipartisan support. There is also pressure to fix the way Medicare reimburses doctors, which is something Congress addresses annually, and Senate Republican leader Mitch McConnell (KY) has mentioned extending current tax breaks.

The most pressing item, however, will be funding the government beyond the temporary spending measure that expires December 11. This means either another continuing resolution or an omnibus spending bill. While both would keep the government running, there are big differences between the two. A continuing resolution would freeze funding in place, while an omnibus allows for changes.

Senate Appropriations chairwoman Barbara Mikulski (D-MD) and House Appropriations chairman Harold Rogers (R-KY) have directed their staffs to work on an omnibus package. The starting point for an omnibus funding bill was planted in late 2013, when a bipartisan budget agreement dictated the spending levels for 2014 and 2015. Spending for 2015 was limited to less than $2 billion above 2014 levels and set caps for defense and non-defense discretionary spending. The result is that the major gaps on individual spending bills that so often disrupt appropriations negotiations largely do not exist; unless an omnibus bill is loaded down with unrelated policy items, it could stand a solid chance for passage.

However, one issue that could present a barrier is funding to combat the Ebola virus. The administration proposed a $6.18 billion emergency spending request on November 5. The emergency designation means the spending would not have to be offset by cuts, which could draw opposition from Republicans who want to hold the line on spending caps. At the same time, the administration has requested expedited treatment and the spending bill for 2015 could be the most direct route.

Preserve Funding for Nursing Programs in FY 2015

Contact Your Representative and Senators Today

Before December 11, members of Congress will determine how to fund the government for fiscal year (FY) 2015, including funding for the Title VIII Nursing Workforce Development Programs at the Health Resources and Services Administration. These important programs provide the main federal funding for the education of nurses, nurse faculty, and nurse researchers in the United States. The continuing shortages of nurses and nurse educators pose real challenges to our current health care system as well as emerging health issues. Fortunately, the Title VIII programs are structured to address the educational, retention, and recruitment needs of the nursing workforce, but the programs cannot meet this need without continued, sustained funding. As background information, the current Title VIII funding chart follows:

Current Status

Title VIII Nursing Workforce Development Programs
(In Thousands)

Nursing Workforce Development Programs

FY 2012 FY 2013

FY 2014
Final Omnibus Bill

FY 2015
President’s Request

FY 2015
Appropriations Subcommittee

Advanced Education Nursing 






Comprehensive Geriatric Education






NURSE Corps Scholarship & Loan Repayment Program






Nurse Education, Practice &
Retention Grants






Nursing Faculty Loan Program






Nursing Workforce Diversity






Total, Title VIII






NB – The House Appropriations Committee has not considered the appropriations bill - HHS-Education-Labor - that contains Title VIII funding.


Call, fax, or email your representatives and senators and urge them to fund the Title VIII Nursing Workforce Development Programs at $251 million in FY 2015. Let them know how important these programs are to ensuring that we have an adequate supply of nurses and nurse educators to meet the health care needs of the nation. Click here to go to template language on the NLN's Government Affairs Action Center.


The National Advisory Council on Nurse Education and Practice (NACNEP) held a meeting last week to discuss the future of nursing practice in the context of interprofessional practice. They identified the strengths, challenges, achievable solutions, and replicable models required and/or available to move from discussion to action. The meeting also focused on nursing practice in alignment with the current shifts in the health care system. The goals of the meeting were to:

  • Identify strengths that align with nursing practices to achieve high quality interprofessional practice-based care
  • Describe the challenges faced by nursing practice in preparing for and furthering interprofessional practice-based care, preparation of the community nurse providers, measurable outcomes, etc.
  • Identify the opportunities that could emerge and advance nursing practice
  • Develop strategies and recommendations to address challenges and produce positive outcomes that will advance the leadership and practice of the nurse on the interprofessional practice team

NACNEP then developed recommendations for Congress including:

  • Removing legislative scope of practice barriers
  • Granting nurse managed health care organizations federally qualified health center status along with training and technical assistance
  • Providing training programs and removing the barriers for nurses in primary care to participate and serve as team leaders in medical homes and other primary care models
  • Building an infrastructure for the collection and analysis of primary health care workforce data - ensuring that nursing data is delineated
  • Clearly defining the role of the nurse in the interdisciplinary team
  • Funding demonstration projects that support nurse education programs and collaborate with health systems to develop a nursing workforce that meets the health care needs in a transforming health system
  • Revamping reimbursement models to better reflect the types and levels of services provided by nurses at all levels and other direct providers
  • Revamping current approaches funding fellowships so as to support new and innovative types of advanced training for nurses such as nurse residency programs